Diaphragmatic Endometriosis Presenting as Recurrent Catamenial Pneumothorax: A Case Report

Catamenial pneumothorax is one of the most common extra-pelvic presentations of endometriosis, with the gastrointestinal tract being the most common location. Catamenial pneumothorax is defined as spontaneous recurrent pneumothorax occurring in women of reproductive age in a temporal relationship with menses. Symptoms include dyspnea, sharp chest pain, and hypoxemia. A much rarer presentation is the involvement of endometriosis with the diaphragm. In this case, we present a 31-year-old female who presented with signs of pneumothorax. She has had multiple episodes leading to suspicion of catamenial pneumothorax. However, it wasn't until her surgery that the extent of diaphragmatic involvement, characterized by numerous holes secondary to endometriosis, was discovered. She was surgically treated, which led to a drastic improvement in symptoms and a reduction in subsequent episodes. We hope that this case can add to the current limited literature on diaphragmatic endometriosis cases. Since this patient presented with mainly catamenial pneumothorax symptoms, we urge clinicians to still consider diaphragmatic involvement as a primary cause in patients with recurrent episodes of pneumothorax.

The combined robotic-assisted laparoscopic and thoracic approach in the management of diaphragmatic, pleural and pericardial endometriosis

OBJECTIVE

To demonstrate the advantages of a combined robotic-assisted laparoscopic and thoracic approach in the management of extensive diaphragmatic, pleural and pericardial endometriosis DESIGN: A video article demonstrating excision of endometriosis from pericardium, diaphragm and pleura.

The importance of early diagnosis and treatment of incidental tension pneumothorax during robotic assisted laparoscopy for diaphragmatic endometriosis: a report of two cases

We describe two cases of diaphragmatic endometriosis treated using the robotic assisted laparoscopic approach, in which an incidental tension pneumothorax occurred during the initial inspection and assessment of diaphragmatic lesions. We demonstrate the importance of early diagnosis of this complication and report successful resolution using the thoracic drainage technique. In case one, after the pneumoperitoneum was installed, during the cavity assessment and inspection, small endometriotic lesions were observed in the tendon portion of the diaphragmatic surface. We observed a sudden increase in maximum airway pressures and a reduction in tidal volume, associated with arterial hypotension and hemodynamic instability and bulging of the diaphragm, which led to the diagnosis of a tension pneumothorax. In case two, diaphragmatic endometriotic lesions were also observed after hepatic mobilisation and following visualisation of the endometriotic lesions, an abrupt decrease in the capnography values was observed, consistent with hypertensive pneumothorax. In both cases, even after deflation of the abdominal cavity, hemodynamic instability persisted. We treated both cases with thoracic drainage, which immediately normalised respiratory parameters and resulted in hemodynamic stabilisation, and the surgical procedures were continued. During laparoscopic procedures for the treatment of diaphragmatic endometriosis, the endometriotic lesions can behave as communication hole in the tendon portion of the diaphragmatic surface and the changes in ventilatory patterns and haemodynamic instability should alert the medical team to the development of an incidental tension pneumothorax. The early identification of this complication in both cases allowed rapid intervention for chest drainage and allowed the surgical procedure to continue.

The management of women with thoracic endometriosis: a national survey of British gynaecological endoscopists

OBJECTIVES

This study evaluates current national opinions on screening, diagnosis, and management of thoracic endometriosis.

BACKGROUND

Thoracic endometriosis is a rare but serious condition with four main clinical presentations: pneumothorax, haemoptysis, haemothorax, and pulmonary nodules. There are no specialist centres in the United Kingdom despite growing patient desire for recognition, investigation, and treatment.

METHODS

We distributed a multiple-choice email survey to senior members of the British Society for Gynaecological Endoscopy. Descriptive statistics were used to present the results. Results: We received 67 responses from experienced clinicians having provided over 800 combined years of endometriosis patient care. The majority of respondents managed over 100 endometriosis patients annually, for more than five years. Over one third had never managed a patient with symptomatic thoracic endometriosis; just 9% had managed more than 30 cases over the course of their career. Screening varied by modality with only 4% of clinicians always taking a history of respiratory symptoms while 69% would always screen for diaphragmatic endometriosis during laparoscopy. The management of symptomatic thoracic endometriosis varied widely with the commonest treatment being surgery followed by hormonal therapies. Regarding management, 71% of respondents felt the team should comprise of four or more different specialists, and 56% believed care should be centralised either regionally or nationally.

CONCLUSIONS

Thoracic endometriosis is poorly screened for amongst clinicians with varied management lacking a common diagnostic or therapeutic pathway in the United Kingdom. Specialists expressed a preference for women to be managed in a large multidisciplinary team setting at a regional or national level.

Ultrasonography and Atypical Sites of Endometriosis

In the present pictorial we show the ultrasonographic appearances of endometriosis in atypical sites. Scar endometriosis may present as a hypoechoic solid nodule with hyperechoic spots while umbilical endometriosis may appear as solid or partially cystic areas with ill-defined margins. In the case of endometriosis of the rectus muscle, ultrasonography usually demonstrates a heterogeneous hypoechogenic formation with indistinct edges. Inguinal endometriosis is quite variable in its ultrasonographic presentation showing a completely solid mass or a mixed solid and cystic mass. The typical ultrasonographic finding associated with perineal endometriosis is the presence of a solid lesion near to the episiotomy scar. Under ultrasonography, appendiceal endometriosis is characterized by a solid lesion in the wall of the small bowel, usually well defined. Superficial hepatic endometriosis is characterized by a small hypoechoic lesion interrupting the hepatic capsula, usually hyperechoic. Ultrasound endometriosis of the pancreas is characterized by a small hypoechoic lesion while endometriosis of the kidney is characterized by a hyperechoic small nodule. Diaphragmatic endometriosis showed typically small hypoechoic lesions. Only peripheral nerves can be investigated using ultrasound, with a typical solid appearance. In conclusion, ultrasonography seems to have a fundamental role in the majority of endometriosis cases in "atypical" sites, in all the cases where "typical" clinical findings are present.

Thoracic and diaphragmatic endometriosis: Single-institution experience using novel, broadened diagnostic criteria

Objective:

To describe our experience with the multidisciplinary management of both thoracic/diaphragmatic endometriosis (TED), applying a broadened definition of the “Thoracic endometriosis syndrome (TES)” to define cases.

Material and Methods:

We present a retrospective series of consecutive patients affected by pathology-proven TED, treated at our institution, during a period of 7 years.

Results:

Five women were included. Two patients were referred due to catamenial chest/shoulder pain, one due to recurrent catamenial pneumothorax, and one due to new-onset diaphragmatic hernia. One patient had no thoracic symptoms, but diaphragmatic endometriosis was found during gynecologic laparoscopy for pelvic endometriosis. Endometriosis was histologically confirmed in all cases. After follow-up, all patients remain asymptomatic.

Conclusion:

Broadened TES criteria could increase the incidence of TED and determine better knowledge of this condition. Multidisciplinary, minimally invasive surgery is effective and safe, but should be reserved for tertiary referral centers.